Workers Compensation - The Salvati Insurance Group

Name(Required)

First Last

Email(Required)

Phone(Required)

Legal Business Name(Required)

Website

Years in business(Required)

Hours of Operation

List Any DBA's and subsidiaries (with FEIN numbers) you would like to be included

Description of business activities – type of business, products manufactured, products sold/dispensed, etc

Location

Street Address City State ZIP Code

Different Mailing Address

Mailing Address

Street Address City State ZIP Code

Please provide a very brief summary of employee hiring process

Ex. Interview, background check, call references, driving record pulled, hired

Do you provide employee health plans?

Do you use any subcontractors or independent contractors?

Number of full time employees(Required)

Number of part time employees(Required)

Number of seasonal employees

Number of volunteers

Do any of your employees work primarily from home?(Required)

Employee Roles

Position

Estimated Payroll

Summary of the different positions within your business and their payroll amounts

Current / Prior Workers Comp – 5 Year History (If available)

New Business / No Prior Work Comp

Total dollar amount paid in payroll across all locations in last 12 months

Estimate OK

Current Carrier

If none leave blank

Current Work Comp Premium

Price paid for coverage if available

Number of claims in the last 3 years

Ownership Coverage

Partners / Officers / Owners

Include or Exclude Officer 1 From Coverage

Officer 1 Name

First Last

Officer 1 – Ownership Percentage

Officer 1 – Title

Add 2nd Officer

Include or Exclude Officer 2 From Coverage

Office 2 Name

First Last

Officer 2 – Ownership Percentage

Officer 2 – Title

Add 3rd Officer

Include or Exclude Officer 3 From Coverage

Officer 3 – Name

First Last

Officer 3 – Ownership Percentage

Officer 3 – Title

Do you have a written safety program?

What is the maximum weight (lbs) that employees lift?

Do any employees work underground or over 15ft high?

What training has been given in case of robbery, theft, or other disturbance?

Have any locations been robbed in the last 7 years?

Does your company extract products?

Please list possible chemical exposures

Do you have a security system?(Required)

Do you have cameras?(Required)

Do you have guards?(Required)

Are the Guards Armed?(Required)

What is your estimated annual revenue?

Do you provide group transportation to your employees?

Do any of your employees travel out of state?

Are you licensed to grow/sell/process cannabis?(Required)

License Number

If applicable

Do your employees perform deliveries?

How many company drivers do you have?

Have you had any prior coverage declined, cancelled, or non-renewed in the last three years?

Do you have any unpaid premiums outstanding with any previous workers comp providers?(Required)